2.
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hospitalization, and the NDE Scale [6], a 16-item multiplechoice instrument that signiﬁcantly differentiates persons
who have near-death experiences during a close brush with
death from those who do not [7]. The scale includes questions about cognitive processes (e.g., sense of time speeding
or slowing), affective processes (e.g., feelings of peace or
pleasantness), purportedly paranormal experiences (e.g.,
sense of separation from the physical body), and experienced transcendence (e.g., sense of being in an unearthly
realm or dimension of existence).
Those patients who scored 7 or more points on the NDE
Scale were assigned to the experiencer group. The remaining patients were assigned to the nonexperiencer group.
Following the identiﬁcation of each member of the experiencer group, the next nonexperiencer group patient who
matched that experiencer in age (within 5 years), gender,
and primary diagnosis was assigned to the matched control
group.
All members of the experiencer group and the matched
control group were given a second, extended interview to
assess their cognitive function, quality of life, attitudes
toward life and death, and prior unusual experiences. This
extended interview took between 30 and 60 min, and included the following measures:
1. Cognitive function was assessed with the Mini-Mental State Exam [8], a standard instrument for quantitative assessment.
2. Quality of life prior to the acute cardiac event was
assessed with: a) the Duke Activity Status Index [9],
a 12-item scale of capacity for physical activities that
is highly correlated with peak oxygen uptake; b) the
Network Support Scales [10], brief measures of instrumental support, problem-oriented emotional support, and nonproblem-oriented emotional support, developed to assess susceptibility to coronary artery
disease; and, c) the Perceived Quality of Life Scale
[11], an 11-item measure of need satisfaction developed among intensive care patients.
3. Attitudes toward their illness and toward death were
assessed with; a) the Acceptance of Illness Scale, a
15-item Likert scale developed for this study based on
prior analysis of narrative descriptions of acceptance
of cardiac disease [12]; and, b) the Death Attitudes
Proﬁle [13] a 21-item Likert scale that measures Fear
of Death and Dying; Approach-Oriented Death Acceptance, reﬂecting views of death as a passage to a
pleasant state; Escape-Oriented Death Acceptance, reﬂecting views of death as escape from painful existence;
and Neutral Death Acceptance, reﬂecting views of death
as a reality neither welcomed nor feared.
4. Prior unusual experiences that may predispose patients to near-death experiences were assessed with a
19-item short form of the Survey of Psi Experiences
[14], which addresses “psychic” experiences such as
purported extrasensory perception, purported para-
normal experiences such as deja vu, altered states of
´`
consciousness such as dreams, and related activities
such as meditation.
Further information obtained from patients’ medical
records was used to determine; a) the severity of myocardial
dysfunction on a standardized 4-point scale [15] of “cardiogenic shock,” “severe heart failure,” “heart failure,” and “no
heart failure”; b) the Coronary Prognostic Index [16], a
weighted index based on sex, age, past history, cardiogenic
shock, heart failure, electrocardiogram, and cardiac rhythm;
and, c) proximity to death on a 4-point scale of “loss of vital
signs,” “progression to loss of vital signs likely without
medical intervention,” “condition serious but not near
death,” and “condition not serious.” These evaluations of
the medical records were performed independently by two
physicians or a physician and a nurse, both of whom were
blind to patients’ group assignment. In the event of disagreement on these ratings, the two raters were required to
discuss the case until they reached consensus.
Characteristics assessed as continuous variables are presented as means Ϯ SD, and were analyzed with two-sided t
tests. Characteristics assessed as categorical variables are
presented as number of patients (% of group), and were
analyzed with ␹2 tests. Data derived from the screening
interview were used to compare the near-death experiencers
with the matched control group, and to compare the experiencers with the entire nonexperiencer group. Data derived
from the extended interview and from the medical records
were used to compare the near-death experiencers with the
matched control group only. All analyses were performed
with SPSS software, version 10.1 (SPSS Inc., Chicago, IL).
This study was approved by the Human Investigation
Committee of the University of Virginia Health System.
3. Results
The mean age of the 1595 patients interviewed was 63
years Ϯ 13; 970 patients (61%) were male. A total of 459
patients (29%) were employed, and 353 (22%) lived alone.
Of the 1595 patients, 675 (42%) were admitted to the
cardiac intensive care unit (CCU); the rest were admitted
directly to a step-down cardiac unit. Screening interviews
were conducted in the CCU for 246 patients (15%) and on
the step-down unit for the remaining patients. Screening
interviews were conducted 3.8 Ϯ 3.9 days after admission;
90% of them were conducted within 6 days of admission.
One hundred and sixteen patients (7%) were admitted
with a primary diagnosis of cardiac arrest, including ventricular ﬁbrillation, asystole, and sustained ventricular
tachycardia; 490 (31%) with myocardial infarction; 624
(39%) with unstable angina; and 365 (23%) with other
cardiac diagnoses, including arrythmias, congestive heart
failure, syncope, heart block, pacemaker malfunction, cardiomyopathy, coronary artery disease, and valvular disease.

3.
B. Greyson / General Hospital Psychiatry 25 (2003) 269 –276
Loss of consciousness was reported by 302 patients
(19%), diminution of consciousness by an additional 423
patients (27%), and normal consciousness by 870 patients
(55%). 37 patients (2%) described themselves as having
died, 245 (15%) as having been “close to death,” 428 (27%)
as “not close to death,” and 885 (56%) could not say how
close they had come to death.
Of the 1595 patients interviewed, 27 scored 7 or more
points on the NDE Scale; those were assigned to the experiencer group. The remaining 1568 patients were assigned to
the nonexperiencer group. Control patients matched to
members of the experiencer group on age, gender, and
primary diagnosis were identiﬁed for only 23 of the 27
near-death experiencers. No patients were found in the nonexperiencer group who met matching criteria for the remaining 4 near-death experiencers.
In addition to the 27 patients (2%) who scored 7 or more
points on the NDE Scale in their description of an experience occurring during the current cardiac episode, 81 additional patients (5%) described near-death experiences that
had occurred prior to the current episode; those patients
were not included in the experiencer group for the present
study. Every patient who reported a near-death experience
scored 7 or higher on the NDE Scale, whereas no patient
who denied having a near-death experience did so.
Near-death experiencers, comprising 2% of the entire sample, included 10% of patients admitted with cardiac arrest, 1%
of those with myocardial infarction, 1% of those with unstable
angina, and 1% of those with other cardiac diagnoses.
Baseline characteristics of the sample are presented in
Table 1. The near-death experiencers were signiﬁcantly
younger than the nonexperiencer group, but no signiﬁcant
differences were observed in demographic variables of gender, percent employed at the time of admission, or percent
living alone.
Near-death experiencers did not differ signiﬁcantly from
nonexperiencers matched on age, gender, and diagnosis on
premorbid health status, as assessed by the Duke Activity
Status Index measuring capacity for physical activity, the
Perceived Quality of Life Scale measuring self-reported life
satisfaction, and the Network Support Scales measuring
interpersonal support networks.
The percent of near-death experiences admitted to the
CCU was signiﬁcantly higher than the percent of all nonexperiencers, indicating greater severity of illness; but it
was not higher than the percent of nonexperiencers matched
on age, gender, and diagnosis. The distribution of diagnoses
differed signiﬁcantly between the near-death experiencers
and nonexperiencers, with cardiac arrest being over-represented among the experiencers.
Self-reported descriptions of state of consciousness during the cardiac event differed signiﬁcantly between the
near-death experiencers and nonexperiencers, including
those in the matched control group, with near-death experiencers more frequently describing loss of consciousness.
Self-reported closeness to death also differed signiﬁcantly
271
between the near-death experiencers and the nonexperiencers, including those in the matched control group, with
near-death experiencers more frequently reporting that they
had died or been close to death. Based on review of their
medical records, the near-death experiencers and matched
nonexperiencers did not differ statistically on the 4-point
scale of objective proximity to death, the classiﬁcation of
cardiac dysfunction, or the Coronary Prognostic Index.
The screening interview was conducted for near-death
experiencers signiﬁcantly later after admission than for nonexperiencers, indicating more time required for clinical stabilization, but not later than the screening interviews for
nonexperiencers in the matched control group. Near-death
experiencers did not differ signiﬁcantly from nonexperiencers matched on age, gender, and diagnosis on the MiniMental State Exam, measuring cognitive function.
As dictated by the criteria for assignment to study group,
scores on the NDE Scale were signiﬁcantly higher among
near-death experiencers than among nonexperiencers; the
difference was greater than two orders of magnitude. Table
2 presents the frequency of individual elements of neardeath experiences among the experiencers, the matched
control group, and the entire nonexperiencer group. Differences between the near-death experiencers and each of the
latter groups were signiﬁcant for each individual element at
PϽ.001. Among the 27 near-death experiencers in this
study, NDE Scale scores ranged from 7 to 23, with a mean
of 12.7 and a median of 12. Among the 23 matched nonexperiencers, 21 scored no points on the NDE Scale and the
remaining 2 scored only 1 point. Among the 1568 nonexperiencers in this study, 1503 (96%) scored no points on the
NDE Scale, and all scored 5 points or fewer.
Attitudes and purportedly paranormal experiences of the
near-death experiencers and matched control patients are
presented in Table 3. Near-death experiencers did not differ
signiﬁcantly from nonexperiencers matched on age, gender,
and diagnosis on the Acceptance of Illness Scale.
On the Death Attitudes Proﬁle, near-death experiencers
scored signiﬁcantly higher than matched nonexperiencers
on Approach-Oriented Death Acceptance, reﬂecting views
of death as a passage to a pleasant state; but the two groups
did not differ signiﬁcantly on Fear of Death and Dying,
Escape-Oriented Death Acceptance, or Neutral Death Acceptance.
On the Survey of Psi Experiences, experiencers reported
signiﬁcantly more previous purported paranormal experiences than did the matched nonexperiencers, and marginally
more altered states of consciousness; but the two groups did
not differ signiﬁcantly on purported psychic experiences or
related activities.
4. Discussion
The ﬁndings of this study, the largest survey of neardeath experiences among cardiac patients, conﬁrm and ex-

6.
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B. Greyson / General Hospital Psychiatry 25 (2003) 269 –276
age, of course, reﬂects not the proportion of cardiac arrest
survivors who actually have near-death experiences, but
rather the proportion who are able to recall such experiences
and are willing to relate them to investigators. The amnesia
that often accompanies cardiac arrest may well make it
difﬁcult or impossible for many experiencers to recall at a
later time their subjective experiences during the arrest [19].
That hypothesis may explain the ﬁnding in this study and in
the Dutch study that recall of near-death experiences was
associated with younger age, as older survivors of cardiac
arrest are more likely to suffer greater cerebral ischemia [3].
Another factor that may reduce the frequency of near-death
experience reports is that those patients who do remember
such experiences are often unwilling to disclose them to
health professionals or researchers for fear of being ridiculed or being diagnosed as mentally ill [20].
This study conﬁrmed the utility of the NDE Scale in
identifying patients who describe near-death experiences:
there was a hundredfold difference between the mean scores
of the near-death experiencers and the nonexperiencers, and
each individual item on the scale statistically differentiated
the experiencers both from the matched controls and from
the entire sample of nonexperiencers. Five features of neardeath experiences were reported by more than two-thirds of
the experiencers: an altered sense of time, a sense of being
out of the physical body, seeing or feeling surrounded by
light, and feelings of peace and of joy. Among those ﬁve
features, only time distortion was reported by any of the
matched control patients, and that was reported by only 4%;
while none of these ﬁve features was reported by more than
2% of the entire sample of nonexperiencers.
Neurochemical models proposed to explain near-death
experiences have implicated endorphins, putative unidentiﬁed ketaminelike endogenous hallucinogens, NMDA receptors, serotonin pathways, limbic system activation, temporal
lobe anoxic seizures, and cerebral hypoxia or hypercarbia
[21–22]. However, empirical evidence for a neural substrate
of near-death experiences has remained elusive; and those
models that have been studied empirically, such as the
inﬂuence of blood gases, have been disconﬁrmed [4]. In the
absence of an accepted animal correlate of mystical experience, neuroanatomic data have been largely limited to
anecdotal studies [23–24], although brain imaging studies
of meditators have implicated increased frontal and decreased parietal lobe activity in experiences of cosmic unity
and transcendence [25]. Although the underlying neurologic
basis of near-death experiences remains conjectural at this
point, available anecdotal evidence suggests involvement of
endorphin-induced limbic lobe activity and/or NMDA receptor blockade by putative endogenous neuroprotective
molecules [23].
In this study, near-death experiencers were more likely
than nonexperiencers to have suffered cardiac arrest, reported more loss of consciousness, and took longer to stabilize before they could be interviewed. However, nonexperiencers matched on age, gender, and diagnosis did not
differ from the experiencers on any objective physiological
variable measured in this study. This ﬁnding is perhaps not
surprising, inasmuch as physiological changes were likely
to have occurred only brieﬂy, and with variability amongst
individual patients. Nevertheless, these ﬁndings did not provide any support for physiological models of the etiology of
near-death experiences.
Psychological models proposed to explain near-death
experiences have implicated dissociation or depersonalization as a defense against the threat of death, absorption and
wish-fulﬁlling hallucinations, state-dependent reactivation
of birth memories, regression in the service of the ego, and
reconstruction of distorted or partial memories after a period
of unconsciousness [22,26]. Although there has been some
evidence of dissociative tendencies in experiencers [27],
psychological models of near-death experiences have not
been tested rigorously.
In this study, near-death experiencers reported greater
approach-oriented death acceptance than did nonexperiencers. That ﬁnding of more positive views toward death complements prior research documenting reduced fear of death
and death anxiety among near-death experiencers [28]. Furthermore, near-death experiencers in this study were more
likely than nonexperiencers to believe they had died or been
close to death. Both those ﬁndings are compatible with a
psychological etiology for the experience, if they in fact
preceded it. However, both those ﬁndings could also plausibly be the results of a pleasurable experience during a
close brush with death. It cannot be determined from these
data, collected after the brush with death, whether they were
a cause or an effect of the near-death experience.
Most near-death experiencers themselves endorse a religious or spiritual model for understanding their experiences,
interpreting them as actual separations from their physical
bodies and glimpses of the afterlife [22]. Near-death experiences often exhibit the cardinal phenomenological features
of mystical states and lead to characteristic spiritual growth
that typically follows mystical experiences [29]. Whether or
not near-death experiences can provide any evidence of life
after death is a controversial question, but one that is not
impervious to empirical exploration [30].
We included in this study questions about prior purportedly paranormal experiences, because of previous reports of
such events among near-death experiencers [31]. Experiencers in this study did in fact report more prior purportedly
paranormal experiences than did nonexperiencers. That difference may suggest that persons who believe they have had
paranormal experiences in the past are more likely to report
near-death experiences; or it may suggest that persons who
have near-death experiences are more likely retroactively to
interpret past experiences as paranormal. Again, these data,
collected after the experience, cannot distinguish between
cause and effect. It is notable that experiencers and matched
controls did not differ on reports of prior “psychic” experiences or related activities. That is, although experiencers
are more likely to interpret past experiences as paranormal,

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B. Greyson / General Hospital Psychiatry 25 (2003) 269 –276
they are not more likely to have sought or experienced
behaviors related to paranormal claims.
For four of the 27 near-death experiencers in this study,
no patient subsequently admitted within the 3-year span of
the study matched the experiencers’ age, gender, and diagnosis. Those four unmatched experiencers were a 23-yearold man with ventricular ﬁbrillation, a 49-year-old man with
ventricular ﬁbrillation, a 43-year-old woman with a ventricular tachycardia arrest, and a 64-year-old woman with ventricular ﬁbrillation. These four unmatched experiencers
tended to be younger than those for whom matched control
patients were found. However, the mean ages of the
matched (44.8Ϯ17.0 yrs) and unmatched experiencers
(58.6Ϯ12.3 yrs) were not statistically different (tϭ1.98,
dfϭ25). Likewise, the matched and unmatched experiencers
did not differ signiﬁcantly in gender (␹2ϭ0.34, dfϭ1) or in
diagnosis (␹2ϭ2.85, dfϭ4). Thus there is no basis to suspect
that the failure to ﬁnd matched control patients for four of
the 27 experiencers inﬂuenced any of the statistical comparisons in this study.
No one physiological or psychological model by itself
explains all the common features of near-death experiences.
It is plausible that some features of these experiences may
be attributable to neurochemical mechanisms, whereas others may be understood better as psychological reactions, and
still others may resist explanation pending the development
of new models of mental function [22]. The paradoxical
occurrence of heightened, lucid awareness and logical
thought processes during a period of impaired cerebral
perfusion raises particularly perplexing questions for our
current understanding of consciousness and its relation
to brain function [21,22]. As prior researchers have concluded, a clear sensorium and complex perceptual processes
during a period of apparent clinical death challenge the
concept that consciousness is localized exclusively in the
brain [3,4].
Assessing changes in patients’ lives following their neardeath experiences was beyond the scope of this cross-sectional study. Retrospective studies have suggested a consistent pattern of changes in beliefs, attitudes, and values
following near-death experiences [22,32], some of which
may affect psychosocial adaptation and adherence to treatment. Case studies have elucidated a variety of interpersonal
and intrapsychic problems that may bring experiencers to
the clinical attention of therapists, as well as therapeutic
strategies with which clinicians can broach and manage
these experiences [33]. It would be valuable to corroborate
those reported aftereffects and the efﬁcacy of those therapeutic approaches in a prospective, longitudinal study of a
cohort of near-death experiencers.
Acknowledgments
This study was supported by a research grant from the
Institut fur Grenzgebiete der Psychologie und Psychohy¨
275
giene, Freiburg i. Br., Germany. I am indebted to Ian
Stevenson, M.D., for his help in designing this research; and
to Christina Fritz, R.N., Tiffany Pankow, M.D., and Jim B.
Tucker, M.D., for their invaluable assistance in conducting
patient interviews and evaluating medical records.
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